Ethiopian Hospital Alliance

for Quality 4TH Cycle

Evidence Based Care (EBC)

Project Document and

Change Package

Clinical Service Directorate

November, 2021G.C
Contents
FOREWORD ................................................................................................................................................. i
EXECUTIVE SUMMARY ............................................................................................................................ ii
ACKNOWLEDGMENT .............................................................................................................................. iv
1. Introduction ....................................................................................................................................... 1
1.1. Background ................................................................................................................................. 1
1.2. Rationale of EBC.......................................................................................................................... 2

2. Objective of EBC Project ................................................................................................................. 6

2.1. General Objective ....................................................................................................................... 6

2.2. Specific objectives ...................................................................................................................... 6

3. Project Description ........................................................................................................................... 6

4. Evidence Based Care Key interventions ...................................................................................... 8

5. Project Implementation Strategies ............................................................................................ 36
6. Scope of the Project ....................................................................................................................... 37
6.1 Project boundary ............................................................................................................................ 37
6.2 Deliverables ..................................................................................................................................... 37
6.3 Assumptions.................................................................................................................................... 38

6.4 Constraints ................................................................................................................................. 38

6.5 Potential risks and possible solutions .................................................................................... 38
6.6 Milestones ................................................................................................................................. 39
7. Monitoring and evaluation .......................................................................................................... 40
7.1. List of Key Indicators ................................................................................................................ 40
Logical Framework of the Project ...................................................................................................... 42
FOREWORD

Since its launching in 2012G.C, we have successfully implemented 3 cycles of EHAQ

focusing on: improving client satisfaction, improving CASH & MNCH services and the
CATCH –IT respectively. We have witnessed that EHAQ platform has brought a lot of

changes in terms of creating a platform for collaborative learning among hospitals,

improving the quality of health care services and improving cleanliness and timeliness of
care across the hospitals, just to mention few. This has encouraged us to continue our

effort of strengthening and sustaining the platform by identifying unaddressed

challenges we are facing in the process of health care delivery.
The thematic area selected for the 4th cycle EHAQ is Evidence Based Care (EBC) and it
aims to improve the health care outcome through use of current best scientific and

practical evidences, in conjunction with clinical expertise and patient values to guide
health care decisions. Evidences have shown that effective implementation of EBC has

proven to result in better patient outcomes and a reduction of costs, regardless of

facility or setting. As a result, we have prioritized four service areas that includes

emergency, surgical, neonatal and chronic hospital cares for the implementation of EBC.
Effective implementation of the project requires strong commitment of the hospital

leadership and other stakeholders at all level. As the theme of this cycle is unique in
nature and demands engagement and collaboration of the whole staff, hospitals‟

leaderships are expected to show strong commitment for its effective implementation. It
requires continuous sensitization of the objectives of the cycle and close monitoring for

its implementation. We, at Clinical service directorate, MoH, would like to express our
renewed commitment to support you in your endeavor to implement the project

Lastly, I would like to use this opportunity to express my heartfelt appreciation and
gratitude to all who dedicated their time and expertise in the preparation of this project

documents
Abas Hassan (MPH, PHD)
Clinical Services Directorate, Director

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EXECUTIVE SUMMARY
Background: Evidence-based care (EBC), a fundamental element and key indicator of

high quality patient care, is a paramount to meeting the quadruple aim in healthcare. It
improves the patient experience through providing quality care, enhances patient

outcomes, reduces costs, and empowers clinicians, leading to higher job satisfaction. For
evidence-based care to become the gold standard of practice its barriers must be

overcome and facilitators maximized. Hence, the EHAQ 4th cycle initiative will focus on
EBC by implementing the following three components of Evidence based practices;

External Evidences from Research, Evidence-based Theories, and Opinion Leaders and
Expert panels, Clinical Expertise (i.e., internal evidence generated from outcomes

management or quality improvement projects, a thorough patient assessment and

evaluation and use of available resources) and Patient Preferences and Value.

For EBC application to improve patient outcomes, four services areas were identified
based on evidences obtained from Desk reviews, suggestions from member hospitals,

deliberations with technical Experts and MOH executive management

recommendations. The following are the Priority services:

1. Emergency, Injury and Critical care

2. Surgical Care

3. Neonatal Care
4. OPD Services focusing on Selected NCD conditions (DM, HTN, Chronic

Respiratory Diseases (CRDs) and Mental Health).

Objective: To improve and sustain the provision of evidence based clinical care that

results in improved quality of patient outcome in neonatal, emergency, surgical and

selected NCDs cares among hospitals enrolled to the EHAQ platform and beyond.
Key Intervention: Through the implementation period of this project, the participating

hospitals are expected to improve the patient outcomes of the selected health
conditions by executing Scope-based practice; Protocol based Clinical Practice, Regular
Clinical Audits, Continuous Quality Improvements, Senior Engagement, Efficient Use of

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Resources, redesigning of their systems, Mechanisms to Assure Data Quality
Management, Quality Nursing Care services and Engaging patients and their families.

Expected outcomes: with the successful implementation of the above key

interventions, the project is expected to improve Institutional Neonatal Mortality rate,

Facility emergency department mortality rate, Major surgeries per surgeon, Surgical Site
Infection rate, improved experience of care and Improved selected NCD control.

Project Timeline: October, 2021 – June, 2023.

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ACKNOWLEDGMENT

Ministry of Health Clinical Service Directorate would like to express its gratitude to all

institutions and individuals involved in inception, preparation and writing up of Evidence

based care (EBC) project document and change package for EHAQ 4th cycle. MOH

appreciates the contribution of EHAQ core team which was instrumental in drafting and
finalizing the entire document. We congratulate the multi- disciplinary team and

institutions and all key stakeholders for the publications. The MOH would like to
acknowledge the critical contribution of each of the individuals annexed.

LIST OF NATIONAL EHAQ CORE TEAM

Dr. Ayele Teshome Biruk Kefelegn

Dr. Hillina Tadesse Dr. Dawit Yifru

Dr. Abas Hasen Dr. Manuel Sibhatu

Biniyam Kemal Dr. Ashenafi Beza

Gezashegn Denekew Deneke Ayele

Kasu Tola Hailegabriel Abomsa

Dr. Fekadu Assefa Dr. Aschalew Worku

Esayas Melese Molla Godif

Dr. Tamiru Assefa Desalegn Bayisa

Abebaw Derso Mebratu Massebo

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1. Introduction
1.1. Background
Ministry of Health through second Health Sector Transformation Plan (HSTP-II)
envisions all of its citizens to enjoy quality and equitable access to all types of health

services. To realize this, the MOH and RHBs are leading a sector wide reform to
strengthen and improve the quality of health services in Ethiopia. Hospitals are central

to these reform efforts and a number of recent national initiatives have specifically
sought to improve hospital performance and quality of services. Of the many national

initiatives currently under active implementation is Ethiopian Hospital Alliance for

Quality (EHAQ). It is a learning collaborative based on a model that involves hospitals

exchanging various resources mainly best practices including knowledge, materials and
professional sharing with each other in which supporting and empowering hospitals for

service improvement will be assured.

EHAQ is designed to act as a catalyst to allow this new model of learning to take root
and flourish, connecting hospitals across the country in an effort to accelerate service

quality improvement as clusters and beyond in a given implementation EHAQ‟s cycle

period on selected focus area on which hospitals are expected to achieve palpable

improvement. So far, EHAQ has passed three implementation cycles with major focus
areas selected for each cycle improving client satisfaction, CASH & MNCH services and

the CATCH –IT respectively. Evidence based hospital care is identified and made to be
the focus area for the national EHAQ Program 4th cycle with the aim to improve hospital

adherence to evidence-based decision making practices as a central pieces of service

delivery working culture in hospitals. Bringing visible improvements on professional

practices while reducing hospital wastages, morbidity and mortalities during provision
of emergency, surgical, neonatal and chronic hospital cares are identified as major
milestones for the 4th cycle. As part of EHAQ‟s core guiding principles, there should

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always be thorough scientific discussions among technical experts at different levels and

coupled with robust situational assessments to identify focus areas for each given
EHAQ‟s cycle implementation period.

According to SARA 2018 only 21% of health facilities have emergency triage, none of
the facilities have all emergency tracer medicines and only 14% with necessary

emergency service guidelines. Currently in Ethiopia, availability of essential emergency

service components such as HR, basic medical equipment, effective emergency response

system and adherence to guidelines and protocols are poorly managed putting the
entire hospital service provision activities at greater risks. Similarly, if not worst,

provision of basic and essential surgical, neonatal and chronic cares have been
challenged by many factors leading the country to have high rates of mortality due to

poor quality of care, low patient satisfaction and experience of care, high rates of senior
professionals attritions, resource wastages and organizational failures as indicated on

different national strategies evaluation reports such as HSTP-I, NQS-I, SaLTS, MNCH,
and Mini-EDHS including ARM reports published during the year between 2019-2020.

1.2. Rationale of EBC

Evidence-based care (EBC), a fundamental element and key indicator of high quality

patient care, is a paramount to meeting the quadruple aim in healthcare. It improves the
patient experience through providing quality care, enhances patient outcomes, reduces
costs, and empowers clinicians, leading to higher job satisfaction. (Melnyk, 2017),
(Dotson et al., 2014), (Fridman & Frederickson, 2014; Kim et al., 2016, 2017). To this end,

Clinicians must tailor scientific information derived from population-based studies to

individual patients‟ needs and preferences, and policymakers must identify which

approaches are most likely to succeed for their programs.

For the patients to receive the most effective, up to date and appropriate treatments,
delivered by clinicians with the right skills and experience, EHSTG recommended

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conducting regular audit, ensure the patient gets the right care (evidence based

practice), adequacy of human power (health professionals have up-to-date knowledge

of the most effective diagnostic tests, treatments and procedures) and resources,

including equipment and drugs, consistent utilization of evidence based guidelines and
clinical standards and the implementation of patient focused care.

The National Healthcare Quality and Safety Strategy (2021-2025) stipulated that lack of

designated system to continually avail, update, use and audit the clinical protocols,
HSTQ‟s complexity and vastness to use quarterly, weak monitoring of evidence-based

practice both at the private and public facilities and Weak compliance of evidence-
based practice as the major weakness of the healthcare system.

National Health Service Quality strategy review revealed limited involvement of

clinicians, especially senior specialists; absence of scope-based practice of health

professionals. Furthermore, there are anecdotal reports of unregistered and unlicensed

practitioners, out of scope practices and ethical breaches.

Currently, evidence is formulated and availed through different treatment guidelines,

clinical protocols, and decision support tools. In Ethiopia even though many evidence-
based guidelines are formulated by different bodies for different levels of care as well as
for programmatic methods such as HIV, NCD, TB, and leprosy, there is a gap in their
consistent utilization across all level of care. The national quality strategy review report

indicated that there is lack of harmonization between MOH/MSGD and Regulatory

standards in developing and execution of clinical standards for each type of services.

Health system efficiency measurement deals with measuring and analyzing health

system outputs concerning inputs or vice versa. A recent critical review of the Health
Sector Reforms in Ethiopia points to the fact that besides the issue of ever diminishing

financial inflows to the Health sector relative to population, poor quality of health care;

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mainly occasioned by a variety of inefficiencies at all levels of health care delivery, is one

of the most important concerns of the sector.

Data quality management is a core component of the overall data management process,
and data quality improvement efforts are often closely tied to data

governance programs that aim to ensure data is formatted and used consistently
throughout an organization for evidence based decision making. The Federal Ministry of

Health (FMOH) has been working towards continuously improving data and information
quality within the health sector. However, data quality was not at the required level to

inform decisions makers on health policy, health programs, and allocation of resources.
For instance, the 2018 national Health Data Quality Review (DQR) revealed that there

was still low data quality at health facility level, emphasizing the need to work hard on
lower level of the health system/health facilities to improve the quality of health related

data in the country.

People-centered care is beyond being the dimension of Quality; rather it is a critical

entry point to improve quality of care. Evidence shows that people-centered care is

more effective, costs less, improves health literacy and patient engagement, and is

better prepared to respond to health crises.

Although Ethiopia has made a remarkable effort to improve emergency, injury and

critical care system, just like many LMICs it has a long way to go. The main challenges
identified with regards to EICC system include lack of clarity of scopes and mandates,

lack of laws and regulations crucial to the IECC system and limited career structures and
training for EICC professionals, a visible gap in data quality and comprehensiveness, a

significant gap in proper use and maintenance of equipment, weak multi-sectoral, inter-
sectoral and private sector collaboration, shortage of allocated funds, limited awareness

among the community in EICC conditions, services and utilization of these services.

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Provision of essential surgical care is among the most cost-effective of all health

interventions and would avert about 1.5 million deaths a year, or 6%–7% of all
preventable deaths in LMICs. In general, the large burden of surgical disorders, cost-

effectiveness of essential surgery, and strong public demand for surgical care suggest
that financing essential surgical care along the path to universal health coverage is a

wise decision. Ethiopia has the lowest measured surgical rate in the world. The
application of EBC components to improve surgical care will be implemented in

harmony with the SaLT II initiative.

The current under-five and neonatal mortality rates for the country that stand at 59 and

33 per 1,000 live births, respectively, are still high compared to global average. In
addition, although the reduction in under-five mortality rate was high the neonatal

mortality reduction was not as progressive as expected.

Non-communicable diseases and injuries (NCDIs) have become a major public-health

problem in Ethiopia, resulting in 44% of total annual mortality. The country has

experienced one of the most rapid shifts in NCD burden globally with an estimated 65%
of disability adjusted life years (DALYs) attributable to NCDs by 2040 and is among the

countries least prepared for this transition. Chronic patient-centric care is not yet
integrated across different level of facilities or among providers.

For evidence-based care to become the gold standard of practice EBC barriers must be

overcome and facilitators maximized. Hence, healthcare organizations must build and
sustain a culture and environment of EBC and devise clinical promotion ladders and

performance evaluations that incorporate its use. This project will implement packages
of interventions to improve evidence based care with ultimate aim of improving clinical

outcome for prioritized health conditions.

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2. Objective of EBC Project

2.1. General Objective

To improve and sustain the provision of evidence based clinical care that results in

improved quality of patient outcome in neonatal, emergency, surgical and selected

NCDs cares among hospitals enrolled to the EHAQ platform and beyond.

2.2. Specific objectives

1) To promote and support the implementation of scope-based practice in hospitals

enrolled to the EHAQ platform.

2) To strengthen continuous Quality improvement and culture of learning.

3) To Improve People-Centered Care.

4) To improve patient outcome of priority health conditions identified for this cycle.

3. Project Description
Evidence Based Care (EBC) is the focus area for the national EHAQ Program 4th cycle
with the aim to improve adherence to evidence-based decision making practices as a

central pieces of service delivery across hospitals through EHAQ platform. It is designed
to build a culture where scope based professional practice, evidence and protocol based
guidance, regular clinical audit, continuous quality improvement, clinical leadership,
efficient use of healthcare resource, system redesign, data quality, patient preference

and values are applied in hospital environment to ensure quality health service. The
project has identified four specific clinical service areas where it primarily focus on

Emergency, injury and critical care, Surgical care, Neonatal care and outpatient service
focusing on selected conditions (DM, HTN, Chronic respiratory disease and mental

health). Furthermore, this project has list of change concepts and change ideas where
hospitals are required to execute for successful implementation of the project and
system build-up. The key interventions identified are depicted in the following figure.

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 EBC Organizational Culture and Environment

Context of Caring

Mechanism to avail
high quality
evidences
 Scope Based Practice
 Protocol based

Quality Patient Outcomes

in
Evidence-
Clinical Expertise based
 CQI (Continuous Quality  Emergency Care
clinical
Improvement)  Surgical care
 Clinicians’ Engagement Decision
 Neonatal Care
 Efficiency gain
 OPD Care (DM, HTN , CRD
 Data Quality
&Mental Health)
 System Redesign

Patient
Engagement
 Client Education
 Client Feedback

Figure 1: Conceptual framework to support Evidence Based Practice. Adapted from

© Melnyk & Fineout-Overholt, 2017.

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4. Evidence Based Care Key interventions
The evidence-based care has selected core change concepts with prioritized key

interventions. These concepts are expected to be primarily implemented in the national

focus areas namely:

A. Surgical services
B. Neonatal intensive care unit services

C. Outpatient service and

D. Emergency services.
The following are the lists of change concepts which are expected to be implemented in

a hospital setting at least at the above mentioned nationally selected focus areas to
create an impactful improvement on evidence-based care practices.

Change concepts proposed to be implemented:

1. Scope based practice

2. Standard based clinical services

3. Person centered care

4. Quality nursing care

5. Evidence generation and utilization

6. Surgical service efficiency and safety

7. System redesign and EHSTG Boosters

8. Efficient use of healthcare resources

9. Improve neonatal intensive care

10. Improve Emergency, trauma and critical care

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Change Concept 1. Scope Based Practice

Scope of practice is a model which allows healthcare services provided by a physician or

other healthcare practitioner to be performed based on the level they are authorized to
practice. Such scope for a health care practitioner is defined based on the education,

training, experience, and demonstrated clinical competencies.

As a health care professional, one must keep within his /her scope of practice to ensure

that he/she is practicing safely, effectively and legally. Every institution is expected to
outline its services and establish a scope of practice manual at least on the national

focus areas of surgical service with emphasis on Operation Theater, neonatal intensive
care unit, outpatient case team/ directorate and emergency Unit within its facilities.

The scope of practice manual should be established after assessment of facilities‟

available human resource and services with special emphasis on the aforementioned
national focus areas. The manual should address level of knowledge and experience of

clinical professionals such as nurses‟ involvement based on specialty/ seniority, interns,

general practitioners, residents & consultants when engaging with the units,

interdepartmental consultations, and level of care by specialists and subspecialists.

By implementing scope of practice, a health facility shall expect an improvement in

clinical outcome of patients, efficiency, patient and staff satisfaction and reduced
professional liability. For the details of key interventions to be implemented see the

table below.

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 Table 1. Change concept 1
Change Concept - 1: Hospital has implemented Scope based clinical practice
Key Interventions Verification method
K.I 1: Define scope: based on levels of care Document review
for the selected priority health conditions
K.I 2: Dispose patients to the appropriate Chart audit
scope level by arranging an emergency
and non-emergency triage system based
on the EHSTG Standards.
K.I 3: Client evaluation at the initial point Chart audit
of contact should be by physicians with
the appropriate level of scope
K.I 4: All consultations are carried out by Chart audit
senior residents and above
Remark
a. Scope needs to be defined for
a. Different levels of physicians - 4 levels of care (Intern, GP and
Junior residents, Senior residents, Consultants)
b. Specialists and sub-specialists in order for preventing
fragmentation of care
c. Interdepartmental consultations (At least Senior residents and
above)
d. Different level of nurses and other health professionals based on
specialty, year of experience
e. All scopes should be based on scientific background and local
and international experiences
b. If the required provider level is not available, the client should be
seen by the highest available scope and referred if required
Triage has to be done by at least GPs and above
Patients referred from other facilities should be seen by at least 1 step
higher professional from referring clinician
Referral clinics should be covered by the responsible specialist or sub-
specialist
- Based on the hospital tier level all consultation responses should be
made by senior residents if not available, by consultants
- In a setup where the above aren‟t available, the most senior clinician for
the setup should respond to the consultation
- Consultation requests, request time, responses & response time should
be recorded appropriately
- All elective surgeries should be done in the presence of the senior
physician
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Change Concept 2. Standard Based Clinical Service

A protocol states the course of action to be adopted by people working within a

particular organization, profession or service. Clinical protocols are basically rules of how
to proceed in certain situations. They provide health care practitioners with parameters

in which to operate. The term „code of practice‟ may be used synonymously with clinical
protocols. One way of supporting implementation of evidence-based practice is

through evidence-based clinical practice guidelines and protocols.

Your institution is expected to initially understand what the major clinical activity related

problems are, review literatures and have a brain storming discussion with experts on
ways to solve the problem, create a summary of clearly outlined agreed points,

standardize protocol template. Once the protocol is finalized, provide orientation for
implementing staff. The health facility is expected to avail clinical protocols and

adopt/adapt treatment guidelines at least in the national focus areas of Surgical Service
(special emphasis in operation theater), Neonatal Intensive care unit (Admission,

Discharge, feeding ), Outpatient Department (starting from Triage, Queue management

system, consultation, appointment system) & Emergency Department/unit (Emergency

triage, Emergency Procedures, Consultation, round, patient transfer).

By implementing protocol based clinical service a health facility is expected to increase

efficiency of health care services and resources, increase in clinical outcome of patients

as they are managed based on evidence, patient safety, and increase in satisfaction of
patients. For the details of key interventions to be implemented see the table below.

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Table 2. Change concept 2

Change Concept 2. Standard Based Clinical Service

Key Interventions
K.I 1. Prepare adapt or adopt guideline or - Document Review
protocol based on hospital morbidity and
mortality burden of priority focus area for:
- Consultation
- Round
- Selected nursing procedures
- Patient transportation
- Bad news breaking
- Surgical scheduling
- Standard treatment guideline
Verification method
Remark
- Focus area for protocol establishment
should at least address national focus areas
for EBC: surgical Services, OPD Clinics,
Emergency Services, and Neonatal ICU.
- Adopt/adapted STG should have, brief
description of the diseases, diagnostic
modality, treatment modality

K.I 2. Avail the established Protocol / STG to - Document review
Clinical Staff - Clinician Interview
- Observation
K.I 3. Monitor the consistent utilization of the - Selected staff interview
clinical protocols - Chart Audit
- Ensure orientation training is provided to
the staff,
- protocol is printed and given in booklet
form to clinical staff
- The facility should conduct regular clinical
audit to ensure the implementation of STG
and Clinical protocols at least in the
aforementioned focus areas.

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Change Concept 3. Person Centered care
Improving healthcare safety, quality, and coordination, as well as quality of life, are
important aims of caring for persons of all age groups. Person-centered care is an

approach to meet these aims in such a way that assures the privacy of individuals‟ health
and life goals in their care planning and in their actual care. The Institute of Medicine

identified patient-centered care as one of the six pillars of quality health care and
described it as “providing care that is respectful and responsive to individual patient

preferences, needs, and values and ensuring that patient values guide all clinical
decisions.”

The institution is expected to develop a client/person centered care protocol by

assessing the needs of the clients and the demand of the facility. Starting from the
hospital premise, reception service, clinical information provision, involvement of clients

in their care and care plan, health information provision platforms, support groups for
chronic patients, appointment system arrangement and so on.

By implementing person centered care interventions, the institution is expected to

improve clinical outcome and client satisfaction. For the details of key interventions to
be implemented see the table below.

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Table 3. Change concept 3

Change Concept 3: Persons centered care

Key Interventions Verification method Remark
K.I 1. Establish health literacy Observation - The unit should be established and be accounted for Medical
unit/desk with full time working Director
health care provider/s Document review - - The unit should have trained HCP, the HCP can rotate in fixed
letter of assignment term ( Nurse, HO or Physician)
- The facility will assign coordinator/ focal
- The health literacy unit should have a register entailing of the
patients full name , address, DX, information provided, contact
number at least
K.I 2. Clinical information Observation - Leaflets and/posters for clients and health care providers
standardization - prepare education - Local language use is advised
materials (prioritized and for the - Audio visual Health education material is recommended
selected prioritized health
conditions)

K.I 3. Comprehensive Information - Client interview - Information provision should address clinical diagnosis, treatment
provision is delivered entirely and - Phone call interview options and plan, subsequent follow up scheme and parameters,
consistently expected life style modifications
- patient preference was heard in treatment options
- Mechanism established to address patient and family concern
K.I 4. Practice patient discharge - Observation - Hospital established a protocol for discharge planning
planning - document review - Create and standardize discharge plan format for selected
- Client interview diseases based on hospital morbidity and mortality
- Attach discharge plan on every patients admitted
- Regular monitoring mechanism in place to assess the practice
K.I 5. Regular Client awareness and Document review - Design mechanism to assess the awareness and knowledge
knowledge audit and identified audit
gaps linked with QI projects Client interview - Regular performance report review (at least every two weeks)
involving key stakeholders

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 - Data driven QI projects conducted based on identified gaps
K.I 6. Control pain for all Document review / - Establish pain clinic or integrate to the existing all the service
emergency, outpatient and client interview delivery points
admitted patients Observation - Prepare/adapt pain management protocol
- Pain assessed in a regularly as 5th V/S, Integrate documentation
with the existing V/S sheet
- Pain managed accordingly (According to prepared protocol)
- Advocate pain management through use of different methods -
“Zero tolerance for pain” posters in all wards and rooms,
- Address clients with chronic pain and those requiring palliative
care
- Assign focal person for pain management
K.I 7. Regular audit for adequacy of Document review - Regular performance report review (at least every two weeks)
pain control and identified gaps involving key stakeholders
linked with QI projects - Data driven QI projects conducted based on identified gaps

K.I 8 The hospital has established Document review - Establish or strengthen a social service unit
hospital based social service which - Has a guideline/ protocol for the functions
addresses the psycho-social care - Regular audit conducted and improvements made
needs of clients

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Change Concept 4. Quality Nursing Care

Quality nursing care is an integration of research evidence, clinical expertise, and a

patient‟s preference. This problem-solving approach to clinical practice encourages
nurse to provide individualized patient care and this leads to better patient outcome

which can decrease demand to healthcare resource.

During the implementation of this change concept the institution should primarily focus

on establishing and conducting regular nursing clinical audit, establish a protocol for
most common nursing procedures and provide orientation, conduct regular nursing

round and shift handover, implement package/bundle of ICU care (enteral nutrition,
gastric ulcer prophylaxis), regular assessment of selected nursing procedure knowledge,

attitude and practice with link to quality improvement project.

By implementing this change concept, the institution is expected to improve patient

outcome and nursing staff satisfaction. For the details of key interventions to be

implemented see the table below.

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Table 4. Change concept 4

Change Concept 4: - improving quality of nursing care

Key Interventions Verification method Remark
K.I 1 Nursing care protocol and Document review - Have a nursing care protocol known and adhered by
procedure prepared for prioritized the nursing staff
health conditions - Key Nursing Procedures ( IV line secure, NG-Tube
insertion , Catherization etc.) and do regular KAP
assessment
K.I 2 Regular nursing care audit and Document review - Establish nursing care round and audit team with TOR
identified gaps linked with QI project - Audit should address the implementation and quality of
nursing process, patient monitoring, pain management,
medication administration and client education (Audit
against the standards set under K.I -1)
- Regular performance report review (Every month)
involving key stakeholders
- Data driven QI projects conducted based on identified
gaps
K.I 3 Conduct daily nursing round Document review - Performance reports linked with QI project
(prepare round packages - Emergency - 1 hour vs 3 hrs. nursing round for 4P‟s, Protocolize - to
preparedness, shift handover, Chart audit whom and how, formats prepared
attendance, dressing code adherence,
Observation
cleanliness etc.)

K.I 4 Implement ICU nursing care Document review - Protocolize - ICU nursing care package with their
packages as per the standard indications and implementation requirements
Chart audit - The package should at least address V/S and fluid
balance monitoring requirements, enteral nutrition, GI
prophylaxis, DVT prophylaxis and medication
administration
- Implementation evidences - client chart formats should
be adopted/adapted for documenting all nursing care

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 services provided to the client
K.I 5 Established a skill Lab and Document review, - Established a skill Lab
regular need based capacity building observation - Conducted Regular capacity building based on identified
for nursing staff gaps
Attendance - Participating in MDT meeting, round, audit, and research
(protocol and document)
K.I 6 Standardizing nursing stations Observation - Availability of Nursing station
- Location of the nursing station easily accessible for
patients
- There should be a reception service available at nursing
station
- There should at least be 1 desktop available at nursing
station with important information on patient admission
and status in the wards
- There should be a TV , health education material and
different protocols available at the nursing station
K.I 7 Patient preference included in Document review - Patient clearly understand the diseases process
decision making (Protocol) - Involvement in care plan, intervention, expected
discharge planning, estimated cost, and expected
Patient interview outcome

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Change Concept 5. Evidence generation and utilization
In healthcare, decision makers rely on high-quality data. The issue is not whether the
quality information is important but rather how it can be achieved. Establishing standard

protocols for documentation of data comes prior to measuring. That is, data can be
identified as high quality only when they conform to a recognized standard. Establishing

a system that ensure conformance with the standard is the main task that needs every
stakeholders‟ engagement.

In the EHAQ 4th cycle proposed change packages are implementation of partial or fully

automated electronic medical record system, chart audits for completeness and quality,
use of locally generated data for improvement of clinical care in emergency, neonatal,

surgical and outpatient care. After Implementation of these change packages, the facility
is expected to have a reliable data for decision making in the clinical process and

intervention prioritization. For the details of key interventions to be implemented see

the table below.

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Table5. Change concept 5

Change Concept 5. Evidence generation and utilization

Key Interventions Verification method Remark
K.I 1- Implement electronic medical record Observation - Implementation of full automation of medical records
system – fully automated - Regular capacity building for staffs

K.I 2- Chart audit system for completeness Chart review - Established team for chart audit team
- System established for charts audit to improve proper
documentation practice
K.I 3- DHIS2 implementation completeness Document review - Availability of adequate number of data collection tools
and timeliness ( registers, tally sheet and reporting format)
- Mechanism established to check proper 20utilization
and completeness of data
- There is timely and complete report of data to
appropriate body
- Conducted analysis and discussed before reporting
(PMT)
K.I 4 There is a regular mechanism to ensure Document review - Regular LQAS/DQA conducted by the HMIS Team
quality of data - Verified by PMT

K.I 5 Regular data driven decision making is Document review - There is data analysis, facility-based data utilization and
practiced institutional QI project devised based on data findings
- Data quality triangulation between units
- Facility plan is based on in house generated data

20
Change Concept 6. Surgical service efficiency and safety
Access to Emergency and essential surgical care (EESC) is one of the prioritized global
initiatives with the aim of improving access to safe, affordable and timely care for the

population. Following this global i`nitiative Ethiopia launched the first surgical care
strategy (SaLTS) in 2016. The new surgical care strategic plan (SaLTS II) identified Access,

efficiency and safety as the key focus areas.

EHAQ 4th cycle focuses on change packages addressing optimizing operating table
utilization (table productivity), OR patient preparation rooms, reducing cancelations,

building team functions, regular performance audits and improvement plans,

establishing a day care surgery. For the details of key interventions to be implemented

see the table below.

21
Table 6. Change concept 6

Change Concept 6. Surgical service efficiency and safety

Key Interventions Verification method Remark
K.I 1: Standardize OR efficiency and the Document review a. Number of table is as per the requirement of
minimum productivity per table OR register review hospital tier level
b. Minimum of 3 cases per table per day
c. 1st case induction time - 8 am
d. Time between cases – 20 minutes
e. 2-3 shift implementation - Morning, afternoon and
private wing
f. Format utilization and schedule notification system
for head nurse and scrub nurses (prior
preparedness for adequate drape and required
instruments and suturing materials)
g. Regular monitoring mechanism linked with quality
improvement project
h. Elective surgical service productivity - >90% of the
initial performance plan
K.I 2: Establish OR patient preparation unit Observation a. Prepared OR patient preparation unit
K.I 3 : Implement measures to reduce Observation a. Establish multi-disciplinary preadmission evaluation
cancellation Document review clinic
Patient interview b. Standardize preoperative work-ups
c. Regular monitoring mechanism linked with quality
improvement project
K.I 4 Standardize and monitor pre-elective Document review a. Protocolize - Preoperative and postoperative
and postoperative hospital stay hospital stay
b. Regular monitoring mechanism linked with
improvement and/or accountability mechanisms
for the identified gaps with
K.I 5 Establish surgical governance and Document review a. OR led by OR director

22
management structure that ensures team Staff interview b. Department specific teams - for multi-specialty
functions hospitals
c. Pre-surgical meeting on daily basis
d. Daily OR director and coordinators monitoring
mechanism linked with quality improvement
project and/or accountability mechanisms for the
identified gaps
K.I 6 Establish Day care surgery unit and Observation a. Protocolize - define day care surgery clinical
ensure its active functioning Document review conditions for each department and ensure
Staff interview necessary infrastructure
K.I 7 Regular performance audit and Document review a. Regular performance report review (at least every
identified gaps linked with QI and/or Minutes two weeks) involving key stakeholders
accountability mechanisms Action plan b. Data driven QI projects conducted based on
Implementation identified gap
reports, Project
documents
K.I 8 Established system of monitoring the Chart review a. Regular audit conducted for the completeness of
adherence and completeness of Surgical SSC
Safety Checklist (SSC) in the operating b. Regular mechanism of implementing a direct
theater observation in the Operating theater for adherence
to the SSC
K.I 9 Established system of SSI tracking and a. Institution integrated the SSI registers in service
intervention to reduce SSI areas and monitor utilization
b. Establish a system of close follow-up for sign and
symptoms of SSI for each patient ( WHO SSI
checklist, wound assessment and documentation
on charts for every patient)
c. Mechanism established for SSI tracking After
discharge

23
Change Concept 7. System redesign and EHSTG Boosters
System redesign in a hospital setting involves making systematic changes to all
segments of hospital service provision process in order to improve the quality,

efficiency, and effectiveness of patient care. It requires thinking through from the patient
perspective, identifying where delays, unnecessary steps or potential for error are built

into the process, and then redesigning the process to remove them and dramatically
improve the quality of care. For successful hospital system redesign, top hospital

management, clinical leader and front-line staffs must be engaged. For this purpose, this
project gives due attention to continuous quality improvement, clinical audit and senior

physician engagement. For the details of key interventions to be implemented see the
table below.

24
Table 7. Change concept 7
Change Concept 7. System redesign and EHSTG Boosters
Key Interventions Verification method
K.I 1: Establish a triage system which is Observation
well equipped and facilitate one stop Document review
triage, registration and cashier service
and accommodate for the needs of
highly infectious cases
K.I 2: OPD clinics meets all the Observation
minimum standards required for an Document review
examination room
K.I 3: Early Initiation of Outpatient Observation
Clinics and block-based Appointment Document review
System Patient interview
K.I 4: Hospitals have separate Pediatric Document review
Wards composed of separate critical, Observation
general, SAM, isolation and procedure
rooms.
Remark
- Pre-triage set up screen for highly infectious cases and
isolate them
- Diagnostic triage tool kit - BP apparatus, stethoscope,
pulse oximeter, glucometer, weighing scale
- Cough corner and cough clinic
- Adhere to EHSTG guideline recommendation
- Well designed with good lighting
- Well ventilated and ensures privacy
- Well furnished - a table with at least two chairs
- Well equipped - at least BP apparatus, stethoscope, reflex
hammer (weighing scare and glucometer at least for
department pools)
- Hand washing/hygiene facility
- Adhere to EHSTG guideline recommendation
- Protocolize - start time, service and academic activities to
be conducted in parallel, lunch time service
- Block based appointment system is in place
- Make Clinics functional during lunch/break hour
- Divide Clinic work hours based, For specialty Service to
morning and afternoon hours (for general & specialized
Hospitals)
- Regularly assess patients not seen same day
- Established pediatric ward with at least Therapeutic
feeding room for children with complicated SAM, Pediatric
ICU or at least HDU for critically ill children next to the
nursing station, Isolation room , procedure room
- All ward room paintings are child friendly
25

K.I 5: The hospital should have a Document review
rehabilitation and palliative care Observation
service with necessary equipment
K.I 6:The hospital has a general and Document review
Biomedical equipment maintenance Observation
center with adequate resources
K.I 7: The hospital establishes and Document review
institutionalizes Human Resources
Information Management Systems
- national guidelines and job aids should be readily
available
- Protocol for rounds and clinical care
- Vital signs are measured with stated protocol
- Growth monitoring is performed for all U5 children
admitted to the ward
Pain management accordingly practiced
- Adhere to EHSTG guideline recommendation
- Integrated or separate rehabilitation and palliative service
- Established physiotherapy service
- With regard to palliative care services, the hospital should
at least provide good pain and symptom control for both
in and out patients
- Technical personnel, sufficient space and adequate
ventilation to conduct maintenance and repair (e.g.,
electrical, water, sanitation, sewerage and ventilation) and
equipment.
- Appropriate tools and testing equipment to perform
repairs, as well as procedures to ensure the routine
calibration of the testing equipment is performed as
required
- Conducts regular preventive maintenance for all facilities
and operating systems (e.g., electrical, water, sanitation,
sewerage and ventilation) to ensure patient and staff safety
and comfort.
- There is a notification and work order system for facility
and operating system (e.g., electrical, water, sanitation,
sewerage and ventilation) repairs.
- The hospital HRIS in place
26
(HRIS) that enhance the HR
management functions.
K.I 8: The hospital has a human Document review Review a copy of the annual human resource
resource development plan that development plan/ HRDP based on need assessment by
addresses staff numbers, skill mix and HR department:
staff training and development. - Check Plan address skill mix for short term trainings
(offsite and onsite), long term trainings
- Ensure that the plan by HR department addresses staff
numbers, necessary budget and training schedule on the
basis of need assessment with departments
- Check the plan approved by GB and SMT
Check whether the plan implemented, evaluated or not
 HR Management Manual
K.I 9 Standardize food and beverage Observation - Establish facility specific menu
service Documentations - Monitoring mechanism is established for assuring the
quality of catering services
- Establish patient feedback and monitoring mechanism
- Hospital has food and beverage service manual
K.I 10. Standardize duty room service - Observation - Duty rooms should be gender based not profession based
provision - Staff Interview - Duty bed should be available to half duty team
- There should be at least desktop computer with connection
to internet or reference books loaded on computer and TV.
- There should be a water boiler
K.I 11. Improve functionality of Document review - Protocol - Prioritized equipment list with an inspection
medical equipment’s by establishing Staff interview and preventive maintenance plan
Medical Equipment Management - Prioritized equipment's should include lifesaving and
information system. support machines which include but not limited to
anesthesia machines, OR tables, mechanical ventilators, X-
ray machines, US machines, CT and MRI machines
- Use of format to document daily activity and equipment
status reports

27
 - Regular calibration and quality assurance programs for
prioritized medical equipment's
- Regular inventory is conducted for medical equipment
K.I 12. Develop a mechanism/system Document review - The strategy addresses prioritized drug lists for
which encourages the rational use of Staff interview monitoring, problem identification and the need for
medications and stipulates mitigation action, identification of underlying causes and motivating
strategy for irrational use of factors, list out and implement possible interventions
medications. - Adapt/adopt recommended management guides with a
focus on the selected prioritized health conditions and
prioritized drug lists
- Prioritized drug list should include 2nd/ 3rd line antibiotics,
narcotic drugs, other expensive drugs
- Problem-based training on pharmacotherapy is
undertaken when indicated/needed
- A system to prescribe, dispense and monitor appropriate
and rational use of the selected and prioritized drugs is
established
- Adhere to Rational use of Antibiotics and Antibiotics
Stewardship Principles
K.I 13. The hospital Conducts regular Document review - The Hospitals has clinical audit team.
clinical audits and links improvement Staff Interview - Regular clinical audit is conducted and finding was
opportunities to CQI. Chart review presented.
- Improvement opportunities identified by audits are linked
with CQI.
K.I 14 Senior physicians are Document Review - Daily senior led multidisciplinary round that addresses
consistently engaged in all clinical care Chart Review nursing care, IPC, client education, clinical pharmacy and
activities and decisions which Staff Interview client satisfaction is made possible
necessitate their involvement. a. Includes weekends and holidays by duty senior
physicians
- All new admissions are audited and co-signed by day time
and duty time assigned senior physicians

28
- Duty senior physician should make handover from day
time senior physician
- Weekly senior chart round practice is implemented and
identified gaps are linked with CQI.
- Chart round should address clinical evaluation and
decision process, use of an appropriate and justified work
up, rational use of drugs, nursing care.
- Quality improvement projects led by senior physicians are
undertaken

29
Change concept 8. Efficient use of healthcare resources
Efficiency is one of the healthcare quality dimensions, related to avoiding waste
including waste of equipment, supplies, ideas, and energy. The Health Sector

Transformation Plan has prioritized three main causes of inefficiencies: procurement;

supply chain management; and, health human resource. Improving the transparency

and accountability of the health procurement system, including evidence- based

specification setting, better forecasting of needs, reduction of procurement time, and

encouraging generic and bulk purchasing, will enhance its efficiency. Further, across the
entire supply chain system, operational efficiency could be improved by improving

storage and distribution of medical commodities, efficient installation of medical

equipment and reduction of wastage. Additionally, allocative and operational efficiency

is expected to be generated by improving procedures pertaining to recruitment,

deployment, training, motivation, and retention of health professionals. For the details

of key interventions to be implemented see the table below.

30
Table 8. Change concept 8

Change Concept 8: Efficient utilization of healthcare resources

Key Interventions Verification method Remark
K.I 1: Explore options to strengthen and Documents Review - Outsourced Non-clinical Services
outsource clinical and non-clinical services - Explore options for outsourcing clinical service
Staff Interview
(including the supply chain management)

K.I 2: Implement different staff incentive Document review - Transparent staff incentive and recognition
and recognition mechanism for enhancing system is in place
efficiency and effectiveness Staff Interview
- Benchmarking of staff incentive mechanisms
K.I 3: Assess sources of inefficiency in Document review - Prioritized mitigation measures are developed
procurement, human resource for health and the progress is continuously monitored.
Staff interview
and supply chain. - Identified gaps are linked to CQI.

K.I 4 :Enhance transparent, accountable Documents Review - Harmonization of planning, budgeting and
and sound resource utilization and budget execution processes, including
financial tracking management system Staff interview producing and disseminating the required
financial and audit reports

31
Change concept 9. Improve neonatal intensive care
Improving the Neonatal ICU service is one of the critical areas that will reduce morbidity
and mortality of neonates in a hospital setting and beyond. Additionally, NICU care for a

hospital setting shows the quality of care and it is by far the known litmus of better
organizational function. The objective of having NICU is to develop the structures for

good care, and to ensure the processes are reliable. Our intention is that if this is based
on the Science of Improvement, on the principles of High Reliability and within the

learning environment of a collaborative network, the outcome for neonates will

continually improve. This will require a clear strategy within which the principles of

quality improvement are embedded, with a commitment to continual improvement and

change. For the details of key interventions to be implemented see the table below.

32
Table 9. Change concept 9

Change concept 9. Improve neonatal intensive care

Key Interventions Verification method Remark

K.I 1: Provide a standard NICU service Document review - Standard requirement for Level I, II and III NICU service
based on the level of the hospital Staff interview establishment

K.I 2: Avail all needed protocols and Document review - Neonatal care guidelines, protocols updated versions
guidelines for Evidence based neonatal Staff Interview - Check charts for adherence of guidelines and protocols
care and adhere to protocols of services

K.I 3: Perform continuous clinical audits
for NICU care services and link with QI
for the findings
K.I 4 :Implement Neonate and Family
centered care
Document review - Quality improvement projects for NICU care services
Staff interview
Documents Review - Establish a family counseling corner
Patient interview - Monitor family participated in decisions starting
evaluation to discharge process

33
Change concept 10. Improve Emergency, trauma and critical care
Emergency, injury and critical care system is a spectrum of activities including pre-
hospital care and transportation; initial evaluation, diagnosis and resuscitation; in

hospital care (emergency units and Intensive care units (ICU)) as well as referral system
to deliver time sensitive health care services for acute illness and injury across the life

course. Although Ethiopia has made a remarkable effort to improve emergency, injury
and critical care system, just like many LMICs it has a long way to go. Dealing with the

ongoing COVID-19 pandemic has asserted the need for coordinated planning and
integrated response at all levels. This will require a clear strategy within which the

principles of quality improvement are embedded, with a commitment to continual

improvement and change. For the details of key interventions to be implemented see

the table below.

34
Table 10. Change concept 10

Change concept 10. Improve Emergency, trauma and critical care

Key Interventions Verification method Remark
K.I 1: Provide a standard emergency Document review - Level emergency departments/ rooms according to
service based on the national levelling Staff interview the emergency levelling document
document. - Upgrade facilities to meet standards
- Expand the use of WHO BEC toolkit in facilities

K.I 2: Provide a standard critical care Document review - Upgrade facilities to meet ICU standards
service based on the national levelling Staff Interview
document.
K.I 3: Avail protocols and guidelines for Document review - Emergency, ICU, trauma, burn and poisoning
Evidence based emergency, injury and Staff interview guidelines/ protocols
critical care and adhere to protocols of -
services
K.I.4. Use of standardized registries to Document review - ED registries, ICU registries and trauma registries
capture a reliable data for evidence-based Staff interview etc..
decisions.
K.I.5. Perform clinical audit for selected Document review - Continuous quality improvement for EICC services
conditions, used to inform QI projects Staff interview

35
 5. Project Implementation Strategies
5.1 Implementation and management of EBC at National level
Nationally Evidence Based Care (EBC) project will be coordinated by Ministry of Health

and RHB are also responsible for managing the project in their respective Regions.
Nationally EHAQ steering committee composed of key stakeholders under State

Minister Program wing leadership and key partners make strategic decisions, provide
guidance and directions. The day-to-day project management of EBC project will be

handled by the EHAQ project team under the Clinical Services Directorate of the MOH.
This team will serve as the engine for driving the project forward. In addition, the Audit

team will be established to prepare the necessary audit tool which helps for the EHAQ

program monitoring and Evaluations.

5.2 Implementation and management of EBC at hospital level

Hospitals are the main actors to the implementation and management of the EHAQ

focus area from the phase of awareness to closing ceremony through which different
steps of activities conducted.

5.2.1 Advocacy and communication

Hospitals need to create awareness and sense of ownership at all level during this phase
including:

1. Orientation of hospital Management and approve through discussion

2. Conduct staff orientation on the goal, expectations and implementation of EBC at

hospital and individual service unit level

5.2.2 Coordination and plan development
1. Customize the project document in the context of their setup

2. Assign focal person from hospital QU as the day to day implementation of EBC
mainly its responsibility

3. Conduct overall baseline assessment of the hospital on the focus area

4. Prepare hospital and service unit level implementation plan

5. Establish Hospital level performance management mechanisms at all level

36
 6. Scope of the Project

6.1 Project boundary

This project is developed to promote an Evidence Based Care that aims to achieve

health service standards and desired health outcomes across all hospitals enrolled to the
EHAQ platform. The project will be implemented from October, 2021 – June, 2023 with

ongoing scaling up of best practices in each hospital and within the cluster hospitals.
In Scope

 Advocating EBC Project among stakeholders to gain a common understanding

 Introducing hospitals key interventions and change package

 Conducting baseline assessment at facility level

 Conducting supportive supervision

 Conducting onsite Mentorship

 Regional performance review meeting in all regions

 Cluster level review meeting and onsite visits

 Benchmarking of best practices

 Conducting preliminary regional assessment

 Conducting national validation and Recognition

 Use of ICT innovations that facilitate planning, implementation and monitoring

of the project

6.2 Deliverables
 Project documents (Project document, EHAQ implementation guideline, change
package, monitoring and evaluation, audit tools)

 Baseline assessment repots of the current EBC in selected interventions from the
hospitals enrolled in EHAQ platform
 Supportive supervision and mentorship reports

37
  Preliminary assessment report

 Final validation/evaluation reports of 4th cycle EHAQ

6.3 Assumptions
 EHAQ platform will remain priority area of MOH top leadership.
 There will be high level commitment from CSD/MSGD/MOH, RHBs and hospital

leadership in implementing the project.

 All necessary sensitization and advocacy of the project is done to bring

stakeholders onboard.
 All necessary resources required (e.g. for QI projects) for the implementation of

the project will be dedicated by MoH/ RHBs and Partners.

 Relevant stakeholders and partners remains in support of the implementation of

the project.
 Hospitals‟ leadership and staff will sustain their commitment and motivation for

implementation of recommended interventions.

 People that are involved at the beginning of the project will remain and stay in

the project until the project is completed.

6.4 Constraints
 Major constraints (e.g., scope, quality, schedule, costs, resources)

 Must be completed by June, 2023 (schedule constraints)

 Must be completed within budget

 Must be completed within the given resource

6.5 Potential risks and possible solutions

6.5.1 Leadership is not aligned/committed

 If the hospitals leadership is not aligned and committed to the project objectives,
there could be limitations in cascading and monitoring its implementation.

38
 Make sure the leadership of the hospitals understood the objectives of the project,

owns it and committed to its implementation through trainings and awareness

creation programs.

6.5.2 Stakeholders not engaged

 Stakeholders who drive the change and can impact the implementation of the

project should be engaged throughout the process. It is also important to assign a

capable team who can effectively coordinate the implementation of the project.

 Get the right people involved in the project and empower them to make informed
decisions. Communicate to stakeholders on the project progress using different

formats as appropriate to their needs.

6.5.3 Resistance to change

 When the hospital leadership, clinical departments and individuals defend status

quo and actively resist the project and organizational change.

 If the hospital leadership and the staff are not motivated to implement the

recommended interventions, change packages, then it would be a challenge for its

successful implementation of the project, to achieve its ultimate goal.

 Communicate the process so that stakeholders are aware of the project goal, its
milestones. Illicit feedback from stakeholders at every stage to keep the project on

track or to mitigate any issues arising.

6.6 Milestones
 Project documents approved by October 31/2021
 Launching (kick off) of the project by November 12/2021
 Hospital level assessment finalized by February, 2022
 Preliminary assessment conducted by regions, hospitals for national validation
identified date February, 2023.
 National validation will be finalized by April, 2023
 National recognition of best performing hospitals by June,2021

39
 7. Monitoring and evaluation
The EBC initiative will have a strong monitoring and evaluation framework. A list of key
indicators that will be used to track project implementation is developed. The M &E

framework will be aligned with the existing platforms of the hospital performance and
improvement manual and DHIS2 tool. Key performance indicators for EBC were carefully

selected to indicate the project outcomes. Considerations were given to the broader
aims and objectives of the initiative as well as the opportunities to share for larger

health facilities beyond the Hospitals. The list could be more detailed at the level of
regional health bureaus and hospitals to meet local demands.

Additionally, structured approaches will be designed to regularly follow progress of the

project implementation. Methods and tools for review meetings, supportive supervisions

and mentorship will be defined in the audit tool.

7.1. List of Key Indicators

I. Neonatal Care
1. Institutional Neonatal Death Rate
2. Proportion of Sick Young infant treated for Newborn infection
3. Proportion of low birth weight or premature newborns for whom Kangaroo
Mother Care (KMC) was initiated after delivery
4. Treatment outcome of neonates admitted to NICU
II. NCD
1. Six-monthly control of diabetes among individuals treated for diabetes
2. Proportion of individuals treated for priority mental health disorders
3. Six-monthly control of blood pressure among people treated for hypertension
III. IPD
1. Average Length of Stay (in days)
2. Proportion of nursing care standards met
IV. Emergency and Critical Care
1. Emergency room patients triaged within 5 minutes of arrival
2. Facility emergency department mortality rate
3. Emergency room attendances with length of stay > 24 hours

40
V. Surgical Care
1. Surgical site infection rate
2. Rate of safe surgery checklist utilization
3. Perioperative mortality rate
4. Mean duration of in-hospital pre-elective operative stay
5. Delay for elective surgical admission
6. Major surgeries per surgeon
VI. Cross-Cutting Indicators
1. Essential Drugs Availability
2. Essential laboratory test availability
3. Functionality of medical equipment
4. Proportion of health Facility staffed as per the standard
5. Percentage of health professionals with an active professional license
6. Percentage of health professionals with defined scope of practice
7. Health budget Utilization
VII. Data Quality
1. Reporting Completeness
2. Reporting Timeliness
3. Proportion of reporting consistency check conducted using LQAS
4. Information use score
VIII. Patient Preferences and Value
1. Patient satisfaction

41
Logical Framework of the Project

Objectives & Activities Indicators Means of Verification Assumptions

/Data source
Goal: To create and sustain a culture 1. Reduce Institutional Neonatal Final evaluation report, - Resources required for
where scientific and practical Death Rate by --- % HMIS, DHIS2 data the achievement of
evidences, processes and practices are 2. Reduce Facility emergency the outcomes are
applied to improve quality of patient department mortality rate by - secured
outcome in Emergency, Surgical, --- % - The outcomes are
Neonatal and outpatient care in 3. Client satisfaction achieved
Hospital enrolled to the EHAQ 4. Major surgeries per surgeon - All the assumptions
Platform. 5. Six-monthly control of identified for the
diabetes project are in place
6. Six-monthly control of blood
pressure
Outcomes 1. All institutions involved in 4th 1. Assessment reports - Resources required for
1. Scope-based practice is promoted cycle EHAQ implemented 2. Evaluation report the achievement of
and Implemented Scope based practice 3. MOU agreement the outputs are
2. Improved adherence to evidence- a. Proportion of cases seen with MoH secured
based standard operating by professional with right 4. Final evaluation - The outputs are
procedures and practices. scope of practice report, HMIS, achieved
3. Improved Client Satisfaction 2. SOPs and Protocols for clinical DHIS2 data - All the assumptions
4. Improved nursing care quality of practice developed and 5. Assessment report identified for the
the four priority conditions followed for the four priority 6. Client satisfaction project are in place
5. Improved practice of evidence health conditions survey
generation and Utilization 3. Client Satisfaction Score
6. Improved Surgical Care efficiency 4. Nursing care standard met
and safety 5. Information use score
7. Culture of learning that embraces 6. Major surgeries per surgeon
continuous Quality improvement is 7. Proportion of Quality
created Improvement projects
8. Regular clinical Audit is graduated.

42
 consistently conducted
9. Improved Clinicians’’ leadership
competencies
10. Efficient use of Healthcare
Resources
11. Improved NICU
12. Improved Emergency and Trauma
Care
Outputs
1. Scope of Practice defined and
manual is developed
2. Standard guidelines and SOPs are
prepared and availed
3. Health literacy unit/desk is
established
4. Patient and family Consultation
manual is prepared
5. Nursing care protocol and
procedure prepared for prioritized
health conditions
6. Mechanisms to assure data quality
are consistently implemented
7. OR efficiency and the minimum
productivity per table standard is
prepared
8. Staff incentive and recognition
mechanism for enhancing
efficiency and effectiveness is
identified and implemented
8. Proportion of Clinical Audits
Conducted.
9. Clinical leadership competency
score Improved by ----%
10. Proportion of Health Budget
Utilization
11. Treatment outcome of
Neonates Admitted
12. Facility Emergency Mortality
Rate
1.1. % of health professionals with 1. Health - Resources required for
defined scope of practice professionals the execution of the
1.2. Percentage of health personal files activities are secured
professionals with an active 2. Observation of - All the activities are
professional license Guidelines at executed
2. Number of the SOP, Service delivery - All the assumptions
protocols… clinical guidelines points identified for the
prepared 3. Assessment report project are in place
3. Number of QI Projects 4. Assessment report,
conducted. DHIS2 Report
4. Proportion of reporting 5. Assessment report
consistency checked using 6. Assessment report
LQAS 7. Assessment Report
4.1. Reporting timeliness 8. EHSTG Report
4.2. Reporting Completeness 9. Assessment report
5. Number of QI projects led by
senior physicians,
5.1. Multidisciplinary round
protocol is developed and
availed
6. Number of clinical audit tools
43
 9. QI projects focusing on each focus prepared
areas are conducted 7. Number of clinical audit
10. Senior physicians’ engagement is conducted
strengthened 8. Patient and family advisory
11. Clinical Audit is consistently manual is prepared and
conducted based on available availed.
audit tool. 9. Proportion for nursing care
12. All needed protocols and standards met.
guidelines for Evidence based
neonatal care are availed and
adhered to.
13. Protocols and guidelines for
Evidence based emergency, injury
and critical care are availed and
adhered to.
Activities: Means: Cost
See key intervention above See The change concepts and Key TBD
interventions

44